Cardiac Arrhythmia
Diagnosis: Cardiac Arrhythmia and Conduction Disorders
Applicable for MSDRGs: 308, 309, 310
MD documentation should address:
- Presenting symptoms: cardiac rhythm normal, tachy- or bradycardia; SOB/dyspnea (on exertion); lung sounds; respiratory effort and rate; syncopal or presyncopal episodes; palpitations; chest/jaw/arm/or shoulder pain; angina or unstable angina; emotional stress
- CXR findings: (i.e. pulmonary edema; pleural effusions; emphysema; infiltrates; bronchiectasis; cardiomegaly, etc)
- Cardiac study findings (i.e. diastolic/systolic dysfunction; ejection fraction)
- EKG: new findings and subsequent changes (i.e. SVT, atrial fib)
- O2 Sat or ABG Findings (i.e. hypoxia, acute/chronic/acute-on-chronic respiratory failure, hyper- or hypocarbnia)
- Lab values: hypoperfusion of renal or hepatic system; electrolyte abnormalities (DO NOT USE ARROWS)
- Possible contributing conditions: CAD, prior MI; cardiac/vascular surgery; implanted cardiac device; anemia; HTN (benign, malignant/accelerated)
- Evidence of encephalopathy and cause if known (metabolic, specific organ dysfunction)
- Mechanical complication due to cardiac pacemaker or implantable defibrillator
- Treatment with medications, procedures or therapies